April 26, 2011

In Fall of 2010, the movie "Expendables" directed by Sylvester Stallone was released to lukewarm reviews. A patient mentioned to me that though the plot was thin and the dialogue shallow, there was a scene where one of the actors (Randy Couture) accurately described his cauliflower ear.

On a side note, the actor's cauliflower ear is actually real. He was a professional mixed martial arts (MMA) and wrestler before getting into acting.

April 25, 2011

Diane Rehm who hosts an NPR show of her name, suffers from a voice disorder called Spasmodic Dysphonia. On April 18, 2011, she hosted a show on vocal issues with expert guests addressing what makes a healthy voice. The experts range from physician laryngologist Dr. Nazaneen Grant to voice coaches.

Eustachian tube dysfunction is a phenomenon whereby a person is unable to pop their ears to relieve symptoms of ear pressure, clogging, or fullness. It is much akin to the ear pressure a person experiences when flying, but at ground level. Traditionally, treatment of this condition involved medications like steroid nasal sprays and prednisone along with active valsalva. Once medical treatment has failed, ear tube placement has been the step of last resort.

However, a promising new treatment called eustachian tube balloon dilation has been described in March 2011 to address eustachian tube dysfunction at the source surgically rather than indirectly with tube placement across the eardrum. In essence, a balloon is inserted into the eustachian tube and than inflated thereby opening it up (the balloon is "popping" the ear for you). The balloon is than deflated and removed.

Dr. Dennis Poe in Boston, MA is the researcher who first described this technique in March 2011 and at this time, is not offered in many centers. Why? Mainly because of the cost of the balloon itself which is not covered by insurance. The material cost of the balloon is around $2000 or more. Compare this to the cost of a tube which is around $30 or less.

Read more about why this technique is offered in so few places and why it is slow to catch on with ENTs in general.

April 18, 2011

An all-natural insect repellant called nootkatone found in Alaska yellow cedar trees and citrus fruits (like grapefruit) is being developed by the CDC. It is so safe for humans, it is even an FDA-approved food additive.

Nootkatone is not only safe for humans and the environment, it is a highly effective insect repellant. In fact, it is not only a bug repellant, but an insecticide causing death to biting insects like mosquitoes within 15 seconds.

Application of 2% nootkatone will also control ticks for up to 42 days at greater than 97 percent efficacy.

It is non-greasy, dries very quickly, and it has a very pleasant, citrus-y grapefruit odor to it.

Sounds too good to be true... But it is true! The only downside right now is that it is not available in the market, mainly because it is expensive — $4,000 per kilogram for highly purified food-grade material, which is used in parts-per-million amounts as a flavoring agent.

However, there are two companies that are currently working to make it available as insect control, hopefully in the near future!

April 15, 2011

I read with interest a blog post by Robert Krulwich of NPR fame on why there is so much public resistance to accept changes in truth with new scientific discoveries (some of which was new to even me)...

1) Triceratops with their beautifully placed 3 horns is actually the teenage dinosaur version of the adult Torosaurus (who had ugly asymmetric horns). Now... a decision had to be made regarding which name to stick with. Ultimately, "Triceratops" won out, perhaps because of the "Save the Triceratops" Facebook page???

2) The same unfortunately is not true for the Brontosaurus. It was clear that Apatosaurus is the same dinosaur and as such, the "Brontosaurus" name is no more much to the dismay of many lay public...

3) Pluto is no longer a planet... tell that to many elementary school children who are still being taught Pluto is the ninth planet in the solar system.

Well... guess what... The same is true in the ENT medical world... Here's a few of my favorites:

1) We all have FOUR tonsils... not two as many people think. The four tonsils are:

Two palatine tonsils located in the back of the mouth

Adenoid (aka, nasopharyngeal tonsil) which is located in the back of the nose

2) The tongue is able to sense four different taste qualities -- sweet, bitter, sour, and salty. Now hold on... don't forget about umami (or savory added in 1985) which brings it up to five taste sensations... Oooops... there's now possibly a sixth simply called "calcium" which has been proposed in 2008 (but not official yet, but maybe soon).

3) How many sinus cavities are there? Most people are aware of the frontal, maxillary, ethmoid, and sphenoid sinus cavities. You ask an ENT that question and they'll probably answer the same... but if you press harder for other sinus cavities beyond those basic 4? You just might get them to start listing the agger nasi cell, onodi cell, haller cell, concha bullosa, etc.

For that matter, most people believe the nose is just an empty cavity that connects to the sinuses for drainage and allows breathing. Not so fast... The nose contains a midline wall called the septum that divides the nasal cavity left and right. Within each side, there are 3 sets of turbinate tissue (inferior, middle, and superior). For awhile, even in the ENT world, there's been debate whether the superior and even a supreme turbinate is present.

The take home message here is that science constantly evolves and is never quite the universal truth people think it is. It is ever-evolving and changing... just like the iPhone or your computer's microchip.

However, it is not as bad as it used to be... After all, people believed the earth to be flat and that the sun rotated around the earth for centuries... to think or say otherwise resulted in scientists being even executed or arrested!

This special exam is needed in patients where such anatomic determination is not able to be made in the clinic while they are awake. As such, an anesthesiologist would put the patient to sleep using IV medications and when snoring or obstructive events happen, endoscopy is performed.

Areas that will be specifically examined during sleep endoscopy include:

Behind the palate

Uvula

Back of Tongue

Walls of the Throat

Epiglottis

Voicebox

Each of these areas may experience collapse during sleep causing obstructive or snoring symptoms.

Why is this information helpful? Well... once it is apparent where and what is the culprit causing a given patient's problems, surgical treatment can be geared more specifically and directly to the area of concern seen during sedated endoscopy.

April 14, 2011

We have produced a new video demonstrating how vocal cord masses can be injected with medications (like steroids) under endoscopic guidance without the need for any sedation. This video also includes bronchoscopy that was performed at the same time (also without any sedation).

April 12, 2011

Reuters published an interesting story about research that showed doctors don't always recommend treatments to patients that they themselves would pursue if they were sick. In essence, if the doctor was the sick person, they would tend to pursue treatments that carry a higher risk of death but fewer severe side effects whereas patients pursue the exact opposite.

Though the clinical scenarios illustrated in the article/research is not reflective of an ENT practice (colon cancer and bird flu), I do see it quite often in other scenarios... the biggest one being when to perform a tracheostomy... hole placed in the throat for breathing purposes often performed in very sick patients in the ICU.

Trachs are often refused by the patient's family for as long as possible... even weeks until all other avenues have been exhausted before considering a trach.

Although this procedure may sound "scary" and many patients and their families automatically refuse to consider such a procedure, the following (unofficial) survey done on Sermo (online physician community) on February 19, 2008 on physicians nationwide may be illuminating on how worthwhile having this procedure is to recovery.

When US physicians were polled at what point they would consider a tracheostomy on themself or their loved one if prolonged intubation was expected, 50% stated trach should be done within the first 8 days of intubation of which 28% wanted it to be performed within 3-5 days. Only 15% would desire a trach after 12 days or longer intubation.

April 10, 2011

The Doctors TV show actually produced a great (and accurate) segment on a relatively new procedure called sialendoscopy. This procedure allows a surgeon to remove a stone that may be blocking your spit gland from draining saliva into the mouth. This is analogous to a kidney stone which blocks urine from draining from the kidney into the bladder resulting in painful swelling of the kidney (causing flank pain).

How does a person know if they have a salivary gland blockage due to a stone? There is a painful swelling located right in front and/or below the ear if the parotid gland is affected, or under the jawbone if the submandibular gland is blocked.

If the blockage persists long enough, it may lead to an infection of the gland itself (sialadenitis).

Traditionally, if the stone doesn't pass on its own with conservative measures, stone removal required surgical removal of the entire gland or making an incision and removing the stone like it's a tumor mass.

Watch the video of this procedure being performed as shown on The Doctors here.

April 03, 2011

Why August 2012? That's when the patent for singulair, an allergy and asthma medication, goes off-patent. Generic versions of singulair should be expected soon after the patent expires.

For those who don't know... generic versions of medications are much cheaper than brand name medications, but contain the same active ingredient. Here's a list of a few brand name medications relevant in the ENT world with generic names in parentheses.

April 02, 2011

Researchers in Turkey found that there is an association between nasal hair density and risk of asthma developing in patients with seasonal rhinitis patients. No joke... They published their findings in the International Archives of Allergy and Immunology in March 2011.

The rate of asthma found in patients with little or no nasal hair was 44.7% whereas only 16.7% of patients with a dense forest of nasal hair had asthma.

They hypothesize that increased nasal hair improves allergen filtration thereby preventing the allergens from irritating the airway. The assumption here being that allergen irritation of the airway can potentially cause asthma.

IF this is true (and that's a big if)... patients with allergies should be encouraged to grow nice thick nasal hair to prevent future asthma!

April 01, 2011

Vocal cord dysfunction (also known as paradoxical vocal cord movement) is a condition where the true vocal cords (TVC) do not move the way they are supposed to. Normally, the vocal cords move apart (abduct) when breathing and come together (adduct) when talking.

Vocal cord dysfunction is when the vocal cords adduct (come together) when breathing resulting in shortness of breath and at its worst, complete airway obstruction resulting in stridor known as laryngospasm.

The video shown here shows a patient with exercise induced vocal cord dysfunction (her breathing attacks occur only with exercise). The first part of the video shows this patient at rest breathing normally. The latter half of the video shows the patient after exercising and suffering from a mild case of vocal cord dysfunction.

Note how the vocal cords come together briefly with inhalation causing the patient to perceive inadequate breathing.

Treatment depends on finding the trigger and addressing the trigger whether it be allergy, reflux, etc. If all possible triggers have been ruled-out, neuropathic medications like neurontin and elavil can be tried. If the side effects are unacceptable or the medications just do not work, botox injections to the vocal cords can be performed.

Speech therapy can also be pursued in order to learn coping mechanisms to help a patient deal with an attack when it happens.

CBS news published a story on hypoallergenic pets on their website here.

The story did report that pricey pets that claim to be easy on allergy sufferers are probably more hype than true, but than did go on to list dogs and cats that are purportedly hypoallergenic.

The claim for hypoallergenicity is based on hair/fur/dander length or quantity... mainly the shorter or smaller the amount, the less allergenic. However, there are other reasons why hypoallergenic pets are NOT hypoallergenic. These include a pet's saliva and skin which contain the same protein that trigger allergic reactions.

Also, many dog allergy sufferers also have weed, tree, and grass allergies. If your hypoallergenic dog likes to roll in the grass and weed, they are getting that all over them and bringing it into the house and to you. So even if you are not allergic to the dog, you probably are allergic to what's on the dog.

To understand the significance of this development, one needs to understand how traditional allergy shots are made. Currently, allergy companies purify a protein called Fel d1 from cats and make a vial out of it. This purification process is like removing the corn kernels from a cornstalk to put into a can to sell at the supermarket.

Peptide immunotherapy as described in this new research is like making the "essence" of the corn kernel in the lab. For this cat vaccine, the key molecule created is a 7 amino acid long peptide sequence.

The benefits of this novel treatment is the lack of side-effects when the shots are administered (meaning, no waiting around after the shot)... and only four to eight shots per year are required (rather than the weekly injections with current allergy shots).

The optimal dose to use is currently being determined in phase three clinical trials.

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